Information
Editors
Visceral Injuries in Children
Essentials
- Visceral injuries in children are mostly blunt and caused by traffic accidents, falling or tumbling.
- If the trauma mechanism and the child's symptoms suggest a visceral injury, referral to a hospital is always warranted.
- Bleeding from visceral organs is not uncommon in children. The most common visceral injuries comprise rupture of the spleen, the liver or a kidney. The most common pulmonary injuries are pneumothorax and pulmonary contusion. Injuries to the pancreas and to the bowel are clearly more uncommon. Injuries to the heart and to the large vessels are rare in children.
Symptoms and diagnosis
- The essential symptom in a blunt abdominal injury is abdominal pain. When examining the abdomen, look for signs of contusion in the abdominal wall (e.g. a longiform bruising caused by a safety belt). The abdomen is virtually always tender by palpation in a patient with abdominal injury. A typical symptom of injury to the thoracic region is difficulty in breathing and/or dyspnoea.
- Signs of bleeding in children may differ from those of adults.
- Low blood pressure or rapid pulse as signs of arterial insufficiency are not always evident in children with hypovolaemia, but significant blood loss is always associated with decreased peripheral circulation.
- The child may maintain the blood pressure level even if the blood loss is > 25% of the total blood volume. Pulse rate will, however, accelerate markedly in this situation.
- Therefore, in the assessment of an injured child note the temperature of the extremities, paleness of the skin and and the strength of peripheral pulses.
- The diagnosis of an internal bleeding is based on clinical examination. The amount of bleeding may be estimated from the clinical signs and later from the haematocrit value. A single haematocrit determination does not give a reliable picture of the blood loss. The trauma mechanism together with the clinical findings and the general condition of the patient are essential in assessing the amount of bleeding.
- The most essential diagnostic investigation in visceral injuries of children is contrast-enhanced trauma CT scan. There is no clear evidence on the benefits of FAST ultrasonography (= Focussed Assessment Sonography for Trauma) in children.
Treatment
- Even if the treatment of visceral injuries in children is mostly conservative, it is essential to rapidly transport the patient to a unit with facilities for possible surgery ("load and go") Prehospital Emergency Care and for follow-up in an intensive care unit.
- First aid for the bleeding caused by an acute visceral injury consists of physiological saline infusion if the infusion route can be established without delay. If the transport time to the final treatment unit is not long and the patient's condition is haemodynamically stable it is not necessary to establish an infusion route.
- If the patient's condition is haemodynamically unstable or the expected transport time is long, placement of an intravenous line or preferably two using a sufficiently large gauge cannula is necessary.
- Intraosseal infusion is an alternative in emergencies: insert a thick needle in the marrow cavity of the proximal tibia. In very young children the procedure is, however, not necessarily easy.
- A child in a haemodynamically unstable condition has lost at least one quarter of his/her blood volume (20 ml/kg of body weight). At least this amount of saline can be infused rapidly because it does not even completely substitute for the already established loss in circulating volume.
- More than 90% of blunt spleen and liver injuries in children may be treated conservatively. Injuries to the pancreas or kidneys are in general also treated conservatively. Pulmonary contusion and pneumothorax will also heal in most cases with conservative treatment.